Bogdan G. Muntean

Atrial standstill in sinus node disease due to extensive atrial fibrosis: impact on dual chamber pacemaker implantation.

AIMS Atrial standstill is characterized by the absence of atrial activity. We report about a series of cases, in which conventional atrial pacemaker lead implantation in patients with symptomatic sinus node disease failed due to lack of excitable right atrial tissue, thus, prompting the diagnosis of atrial standstill. We hypothesized that mapping of the atria with subsequent identification of myocardium still amenable to atrial pacing would allow dual chamber pacemaker implantation. METHODS AND RESULTS In four patients, atrial lead implantation failed. In these patients, spontaneous or fibrillatory electrical activity was absent but the atria could not be captured despite high stimulation voltages at conventional atrial sites. We suspected partial or complete atrial standstill and subsequently confirmed this hypothesis by conventional (n = 1) or electroanatomical mapping (n = 3). Areas of fibrotic tissue were present in all patients as identified by lack of spontaneous electrical activity and inability of local electrical capture via the mapping catheter. Surviving atrial tissue, which could be electrically captured with subsequent conduction of activity to the atrioventricular (AV) node, was present in three patients. Successful targeted atrial lead implantation at these sites was achieved in all these patients. Isolated sinus node activity without conduction to the atria was found in one patient. CONCLUSION Partial atrial standstill may be present and prevent atrial lead implantation in patients with sinus node disease. In these patients, recognition of partial atrial standstill and identification of surviving muscular islets with connection to the AV node by mapping studies may still allow synchronous AV sequential pacing.

Successful intraprocedural anticoagulation with bivalirudin during pulmonary vein isolation in a patient with known heparin-induced thrombocytopenia type II

We report the case of a 56‐year‐old female who presented with symptomatic paroxysmal atrial fibrillation. Anamnestic heparin‐induced thrombocytopenia (HIT) type II was suspected, and a rapid diagnostic test showed antibodies against platelet factor 4. The heparin‐induced platelet activation‐assay was negative. Radiofrequency pulmonary vein isolation with intraprocedural anticoagulation using bivalirudin was ultimately performed. Dosing was controlled by monitoring the activated clotting time. Post‐procedural blood tests were normal. There were no thromboembolic or bleeding events. Bivalirudin is a therapeutic option for anticoagulation during pulmonary vein isolation procedures in patients with a history of HIT type II.

Wide QRS complex tachycardia in a patient with ischemic cardiomyopathy and prior ventricular tachycardia ablation

CASE REPORT This article reports the case of a 76-year-old patient with multiple implantable cardioverter defibrillator (ICD) interventions of the single chamber ICD. On admission the 12-lead electrocardiogram (ECG) documented a wide QRS complex tachycardia without clearly identifiable P waves. The patient had previously had two ventricular tachycardia (VT) ablations due to VT storms. The resting ECG revealed a sinus rhythm with a wide QRS complex. During the electrophysiological investigation typical atrial flutter could be detected and an ablation of the cavotricuspid isthmus was performed. During the follow-up period, the patient has been free from tachycardia. CONCLUSION The case described emphasizes that a differentiation between supraventricular tachycardia (SVT) and VT based on a stored ECG without an atrial channel can be challenging.

Breitkomplex-Tachykardie bei einem Patienten mit ischämischer Kardiomyopathie und stattgehabter Ablation einer ventrikulären Tachykardie

CASE REPORT This article reports the case of a 76-year-old patient with multiple implantable cardioverter defibrillator (ICD) interventions of the single chamber ICD. On admission the 12-lead electrocardiogram (ECG) documented a wide QRS complex tachycardia without clearly identifiable P waves. The patient had previously had two ventricular tachycardia (VT) ablations due to VT storms. The resting ECG revealed a sinus rhythm with a wide QRS complex. During the electrophysiological investigation typical atrial flutter could be detected and an ablation of the cavotricuspid isthmus was performed. During the follow-up period, the patient has been free from tachycardia. CONCLUSION The case described emphasizes that a differentiation between supraventricular tachycardia (SVT) and VT based on a stored ECG without an atrial channel can be challenging.

[Transseptal puncture after device closure of patent foramen ovale: Is it feasible?].

CASE REPORT The case of a 40-year-old woman with paroxysmal symptomatic atrial fibrillation and implanted occluder of a patent foramen ovale (PFO; AMPLATZER™ Septal Occluder, St. Jude Medical) is reported. Due to the symptomic atrial fibrillation, pulmonary vein isolation was planned. METHODS Under transesophageal, echocardiographic control the transseptal puncture was performed posterior inferior of the occluder without any complications. The pulmonary vein was successfully isolatedusing radiofrequency energy. CONCLUSION This case demonstrates that transseptal puncture in pulmonary vein isolation with an inserted PFO occluder under additional transesophageal, echocardiographic monitoring is safe and feasible.ZusammenfassungFallberichtEs wird über eine 40 Jahre alte Patientin mit paroxysmalem, symptomatischem Vorhofflimmern und implantiertem Occluder eines persistierenden Foramen ovale (PFO; AMPLATZER™ Septal Occluder, St. Jude Medical) berichtet, welche sich bei bestehender antiarrhythmischen Therapie mit Flecainid zur Pulmonalvenenisolation vorstellte.MethodenUnter transösophagealer echokardiographischer Kontrolle erfolgte eine komplikationslose transseptale Punktion posterior inferior des Occluders. Die geplante Pulmonalvenenisolation konnte erfolgreich mittels Radiofrequenzenergie durchgeführt werden.SchlussfolgerungDieses Fallbeispiel zeigt eindrucksvoll, dass eine transseptale Punktion im Rahmen einer Pulmonalvenenisolation bei PFO-Occluder unter zusätzlicher transösophagealer echokardiographischer Kontrolle sicher durchführbar ist.AbstractCase reportThe case of a 40-year-old woman with paroxysmal symptomatic atrial fibrillation and implanted occluder of a patent foramen ovale (PFO; AMPLATZER™ Septal Occluder, St. Jude Medical) is reported. Due to the symptomic atrial fibrillation, pulmonary vein isolation was planned.MethodsUnder transesophageal, echocardiographic control the transseptal puncture was performed posterior inferior of the occluder without any complications. The pulmonary vein was successfully isolatedusing radiofrequency energy.ConclusionThis case demonstrates that transseptal puncture in pulmonary vein isolation with an inserted PFO occluder under additional transesophageal, echocardiographic monitoring is safe and feasible.

Transseptale Punktion nach PFO-Verschluss@@@Transseptal puncture after device closure of patent foramen ovale: Geht das?@@@Is it feasible?

CASE REPORT The case of a 40-year-old woman with paroxysmal symptomatic atrial fibrillation and implanted occluder of a patent foramen ovale (PFO; AMPLATZER™ Septal Occluder, St. Jude Medical) is reported. Due to the symptomic atrial fibrillation, pulmonary vein isolation was planned. METHODS Under transesophageal, echocardiographic control the transseptal puncture was performed posterior inferior of the occluder without any complications. The pulmonary vein was successfully isolatedusing radiofrequency energy. CONCLUSION This case demonstrates that transseptal puncture in pulmonary vein isolation with an inserted PFO occluder under additional transesophageal, echocardiographic monitoring is safe and feasible.ZusammenfassungFallberichtEs wird über eine 40 Jahre alte Patientin mit paroxysmalem, symptomatischem Vorhofflimmern und implantiertem Occluder eines persistierenden Foramen ovale (PFO; AMPLATZER™ Septal Occluder, St. Jude Medical) berichtet, welche sich bei bestehender antiarrhythmischen Therapie mit Flecainid zur Pulmonalvenenisolation vorstellte.MethodenUnter transösophagealer echokardiographischer Kontrolle erfolgte eine komplikationslose transseptale Punktion posterior inferior des Occluders. Die geplante Pulmonalvenenisolation konnte erfolgreich mittels Radiofrequenzenergie durchgeführt werden.SchlussfolgerungDieses Fallbeispiel zeigt eindrucksvoll, dass eine transseptale Punktion im Rahmen einer Pulmonalvenenisolation bei PFO-Occluder unter zusätzlicher transösophagealer echokardiographischer Kontrolle sicher durchführbar ist.AbstractCase reportThe case of a 40-year-old woman with paroxysmal symptomatic atrial fibrillation and implanted occluder of a patent foramen ovale (PFO; AMPLATZER™ Septal Occluder, St. Jude Medical) is reported. Due to the symptomic atrial fibrillation, pulmonary vein isolation was planned.MethodsUnder transesophageal, echocardiographic control the transseptal puncture was performed posterior inferior of the occluder without any complications. The pulmonary vein was successfully isolatedusing radiofrequency energy.ConclusionThis case demonstrates that transseptal puncture in pulmonary vein isolation with an inserted PFO occluder under additional transesophageal, echocardiographic monitoring is safe and feasible.

Transseptale Punktion nach PFO-Verschluss

CASE REPORT The case of a 40-year-old woman with paroxysmal symptomatic atrial fibrillation and implanted occluder of a patent foramen ovale (PFO; AMPLATZER™ Septal Occluder, St. Jude Medical) is reported. Due to the symptomic atrial fibrillation, pulmonary vein isolation was planned. METHODS Under transesophageal, echocardiographic control the transseptal puncture was performed posterior inferior of the occluder without any complications. The pulmonary vein was successfully isolatedusing radiofrequency energy. CONCLUSION This case demonstrates that transseptal puncture in pulmonary vein isolation with an inserted PFO occluder under additional transesophageal, echocardiographic monitoring is safe and feasible.ZusammenfassungFallberichtEs wird über eine 40 Jahre alte Patientin mit paroxysmalem, symptomatischem Vorhofflimmern und implantiertem Occluder eines persistierenden Foramen ovale (PFO; AMPLATZER™ Septal Occluder, St. Jude Medical) berichtet, welche sich bei bestehender antiarrhythmischen Therapie mit Flecainid zur Pulmonalvenenisolation vorstellte.MethodenUnter transösophagealer echokardiographischer Kontrolle erfolgte eine komplikationslose transseptale Punktion posterior inferior des Occluders. Die geplante Pulmonalvenenisolation konnte erfolgreich mittels Radiofrequenzenergie durchgeführt werden.SchlussfolgerungDieses Fallbeispiel zeigt eindrucksvoll, dass eine transseptale Punktion im Rahmen einer Pulmonalvenenisolation bei PFO-Occluder unter zusätzlicher transösophagealer echokardiographischer Kontrolle sicher durchführbar ist.AbstractCase reportThe case of a 40-year-old woman with paroxysmal symptomatic atrial fibrillation and implanted occluder of a patent foramen ovale (PFO; AMPLATZER™ Septal Occluder, St. Jude Medical) is reported. Due to the symptomic atrial fibrillation, pulmonary vein isolation was planned.MethodsUnder transesophageal, echocardiographic control the transseptal puncture was performed posterior inferior of the occluder without any complications. The pulmonary vein was successfully isolatedusing radiofrequency energy.ConclusionThis case demonstrates that transseptal puncture in pulmonary vein isolation with an inserted PFO occluder under additional transesophageal, echocardiographic monitoring is safe and feasible.

Late deterioration of left ventricular function after right ventricular pacemaker implantation.

Objectives: Right ventricular (RV) pacing induces a left bundle branch block pattern on ECG and may promote heart failure. Patients with dual chamber pacemakers (DCPs) who present with progressive reduction in left ventricular ejection fraction (LVEF) secondary to RV pacing are candidates for cardiac resynchronization therapy (CRT). This study analyzes whether upgrading DCP to CRT with the additional implantation of a left ventricular (LV) lead improves LV function in patients with reduced LVEF following DCP implantation. Methods: Twenty-two patients (13 males) implanted with DCPs and a high RV pacing percentage (>90%) were evaluated in term of new-onset heart failure symptoms. The patients were enrolled in this retrospective single-center study after obvious causes for a reduced LVEF were excluded with echocardiography and coronary angiography. In all patients, DCPs were then upgraded to biventricular devices. LVEF was analyzed with a two-sided t-test. QRS duration and brain natriuretic peptide (BNP) levels were analyzed with the unpaired t-test. Results: LVEF declined after DCP implantation from 54±10% to 31±7%, and the mean QRS duration was 161±20 ms during RV pacing. NT-pro BNP levels were elevated (3365±11436 pmol/L). After upgrading to a biventricular device, a biventricular pacing percentage of 98.1±2% was achieved. QRS duration decreased to 108±16 ms and 106±20 ms after 1 and 6 months, respectively. There was a significant increase in LVEF to 38±8% and 41±11% and a decrease in NT-pro BNP levels to 3088±2326 pmol/L and 1860±1838 pmol/L at 1 and 6 months, respectively. Conclusion: Upgrading to CRT may be beneficial in patients with DCPs and heart failure induced by a high RV pacing percentage.

Breitkomplex-Tachykardie bei einem Patienten mit ischämischer Kardiomyopathie und stattgehabter Ablation einer ventrikulären Tachykardie@@@Wide QRS complex tachycardia in a patient with ischemic cardiomyopathy and prior ventricular tachycardia ablation

CASE REPORT This article reports the case of a 76-year-old patient with multiple implantable cardioverter defibrillator (ICD) interventions of the single chamber ICD. On admission the 12-lead electrocardiogram (ECG) documented a wide QRS complex tachycardia without clearly identifiable P waves. The patient had previously had two ventricular tachycardia (VT) ablations due to VT storms. The resting ECG revealed a sinus rhythm with a wide QRS complex. During the electrophysiological investigation typical atrial flutter could be detected and an ablation of the cavotricuspid isthmus was performed. During the follow-up period, the patient has been free from tachycardia. CONCLUSION The case described emphasizes that a differentiation between supraventricular tachycardia (SVT) and VT based on a stored ECG without an atrial channel can be challenging.